Use of NIFC Cholangiography for the Identification of the Anatomy in Biliary Surgery

Use of Near-infrared Incisionless Fluorescent Cholangiography (NIFC) for Identification of the Anatomy in Biliary Surgery Francisco

Authors: A. Ferri, MD; Felice De Stefano, MD; Vicente J. Cogollo, MD; Alejandro Cracco, MD; Emanuele Lo Menzo, MD, PhD, FACS, FASMBS; Mayank Roy, MD, FACS; Fernando Dip, MD, FACS.
Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida.

Summary: Bile duct injuries during laparoscopic cholecystectomy remain a potentially devastating complications and are responsible for major morbidity and prolonged hospitalization1. Visual misperception, anatomical variations in the extrahepatic biliary tree, combined with inflammatory changes and surgeon inexperience in recognizing the anatomy, are among the most common reasons for these injuries. Near-infrared Incisionless Fluorescent Cholangiography (NIFC) has been shown to improve the visualization and identification of the biliary structures compared to traditional white light.

Patient Background: The following case study discusses a 37 years old, morbidly obese woman (BMI 43 Kg/m2) with impaired fasting glucose and no significant surgical history who presented to the clinic with a 3-month history of right upper quadrant (RUQ) abdominal pain, especially after meals. The physical exam revealed tenderness in the RUQ with a negative Murphy sign and no evidence of peritonitis. An ultrasound showed a 3.8 cm gallstone without gallbladder wall thickening and hepatic steatosis. Esophagogastroduodenoscopy did not reveal any pathologic findings. The patient was referred to the bariatric surgery clinic for evaluation in view of her elevated BMI and her comorbidity. After discussing surgical options, the patient elected to undergo a combined laparoscopic sleeve gastrectomy and cholecystectomy using NIFC.

Procedure: Under general anesthesia, the abdominal cavity was accessed through an optical trocar in the supraumbilical position. After insertion of accessory trocars, a sleeve gastrectomy was performed in standard fashion. Next, 3mL of Indocyanine green for Injection, USP (ICG) were injected
intravenously. The gallbladder was cranially retracted. The hepatoduodenal ligament was exposed. Using near-infrared imaging we identified the ICG perfusion times of the liver, common hepatic duct and gallbladder at 1, 12 and 22 minutes after the injection of the ICG, respectively (Figures 2-4).
The cystic duct and cystic artery entrance into the gallbladder were both clearly identified (Figure 5) and transected between clips. The very large and chronically inflamed gallbladder was excised from the liver bed in retrograde fashion and retrieved with the specimen through the umbilicus. All trocar sites were closed with sutures and injected with local anesthesia.

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Use of ICG in Fluorescence Angiography in a Complex AWR

Indocyanine Green use in Fluorescence Guided Surgery

Indocyanine Green Fluorescence Angiography in Complex Abdominal Wall Reconstruction

Lisandro Montorfano, MD; Rene Aleman, MD; Felipe Okida, MD; Fernando Dip, MD, FACS; Samuel Szomstein, MD, FACS, FASMBS; Raul Rosenthal, MD, FACS, FASMBS; Emanuele Lo Menzo, MD, PhD, FACS, FASMBS.


Complex abdominal wall reconstruction (AWR) carries a significant wound morbidity. Adequate myocutaneous flap perfusion is paramount to decrease such morbidity. However, intraoperative evaluation of abdominal wall perfusion can be challenging, time consuming, and inaccurate. Fluorescence guided imaging of the abdominal wall using the Indocyanine Green (ICG) dye provides an accurate and expeditious realtime assessment of the myocutaneous flap vascular perfusion. Adequate blood flow evaluation with this technique contributes to the reduction of postoperative wound complications and improve patient outcomes following complex abdominal wall reconstruction.

Patient Background: The following case study discusses a patient who underwent an open ventral hernia repair, bilateral transversus abdominis release, bilateral myocutaneous flap, insertion of underlay mesh, and excisional debridement of skin after ICG perfusion evaluation.

The patient is a 75-year-old male with a past medical history of chronic alcohol abuse, former smoker, obesity (Body Mass Index of 31.2), prostate cancer, hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post coronary artery bypass graft, hypothyroidism, obstructive sleep apnea, chornic kidney disease and depression who presented with a history of a large incisional hernia following a Whipple procedure, which was further complicated by a wound infection which required debridement (Fig. 1). Despite several months of wound care, he developed a non-healing wound. Based on the hernia related symptoms and the wound status that was precluding a necessary orthopedic procedure, the patient was referred to our clinic for evaluation. After a comprehensive evaluation and case review at a multicenter hernia conference, he was offered an open ventral hernia repair with bilateral transversus abdominis release, bilateral myocutaneous flap and mesh placement.

Procedure: Preoperative antibiotics, subcutaneous heparin, and sequential compression devices were utilized, as per protocol. An incision was made over the old scar from the xyphoid processto the infraumbilical area. After entering the peritoneal cavity from the upper area, the expected multiple adhesions were taken down. The posterior rectus sheath was separated from the rectus muscle all the way lateral until the perforator vessels were identified and protected. The posterior lamella of the posterior rectus sheath and the transverse abdominis muscle were then divided and the dissection continued in the retroperitoneum. A similar dissection was performed on the opposite side. The posterior rectus sheath was closed.

A 20x25mm polypropylene mesh was then placed in the retrorectus space and fixated with absorbable monofilament suture. The anterior rectus sheath was closed under physiologic tension with absorbable monofilament suture. In order to remove the non-healed abdominal wall skin, bilateral cutaneous flaps were created.

After a 3.5 mL intravenous injection of Indocyanine Green (ICG), the abdominal wall skin was then evaluated with the IC-FlowTM Imaging System (Diagnostic Green GmbH Aschheim-Dornach Germany) infrared camera . Based on this evaluation, the non-perfused skin was debrided and excised (approximately 80 cm2 ). Following the insertion of two closed drains, the skin was closed over. The skin was then closed over two closed suction drains. The patient tolerated the surgery well, and he was discharged without complications on post-operative day three. There were no postoperative complications and no hernia recurrence at his 12 months follow up.

For the conclusion, references and images please download the case study here

HTA Approach on Surgical Endoscopy Procedures using ICG

Economic Health Technology Assessment (HTA) Approach on Surgical Endoscopy Procedures using Indocyanine Green (ICG)

Authors: Vettoretto, N; Foglia, E; Ferrario, L; Gerardi, C; Molteni, B; Nocco, U; Lettieri, E; Molfino, S; Baiocchi, G.L; Elmore, U; Rosati, R; Currò, G; Cassinotti, E; Boni, L; Cirocchi, R; Marano, A, Petz, W.L; Arezzo, A; Bonino, M.A; Davini, F; Biondi, A; Anania A; Agresta, A; Silecchia, G.

This paper offers a summary of a number of key findings published in Surgical Endoscopy, April 2020.
Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

A paper published in Surgical Endoscopy, April 2020, undertook a Health Technology Assessment (HTA) approach to investigate the economic, social, ethical and organizational implications related to the adoption of ICG based fluorescence guided surgery, summurizing the key findings.

With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated Questionnaires and self reported interviews. Research included a systematic search of literature. This present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an Health Technology Assessment (HTA) approach, supports “the use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology”.

The use of fluorescence guided vision in minimally invasive surgery, ….as an efficient and economically sustainable technology

Recently image-guided by Indocyanine Green (ICG) fluorescence has been introduced in minimally invasive clinical practice. The fluorescence approach is detected thanks to special cameras that are sensitive to the near infrared (NIR) spectrum. Indocyanine Green (ICG) absorbs near-infrared light (NIR) at wavelengths of 800 to 810 nm. This fluorophore emits fluorescence at 830 nm when bound to tissue proteins if excited, with specific wavelength light in the near-infrared light (NIR) spectrum (w820 nm).

85% of those interviewed believe Indocyanine Green (ICG) Fluorescence Guided Surgery will become standard in the near future

Fifty-six surgeons working in both teaching and community, public and private hospitals (covering 75% of the Italian regions), answered a questionnaire. 66.1% of the respondents already used fluorescence during their everyday practice. 63.3% of the surgeons consider Indocyanine Green (ICG) fluorescence guided surgery as an improvement of their practice, while 62.5% think that this technology can help in surgical education. When asked about the potential growth of Indocyanine Green (ICG), 85% of those interviewed believe that it has the potential to become a standard vision technology, in the near future.

“The use of Indocyanine Green (ICG) is perceived as improving the precision of the surgical technique, the identification of the blood vessels, allowing for a better image quality compared with standard white light”

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Full reference Source: Could fluorescence‑guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment (HTA) summary